The Awakening

Having taken Ambien for insomnia since college, Amanda FitzSimons set out to discover what medical research had to say about the risks of her beloved sleeping pill. The answers just might keep you up at night.

Addiction to sleeping pills. As I type this, that phrase sounds so scary and cliché, the stuff of a Lifetime movie starring Meredith Baxter, crying alone in a dark apartment amid empty bottles of Southern Comfort. What I have, or at least the way I prefer to think of it, sounds a lot less harmful: just one little pill to help me go to sleep at night…every night.

I, like tens of millions of other Americans, take Ambien or its generic equivalents (zolpidem is the active ingredient), which makes the drug by far the country's most popular sleep aid. When I first got a prescription, I was suffering from what doctors call "acute insomnia," i.e., a string of nights in which I stared at the ceiling for hours before finally being able to get some shut-eye. If this pattern of taking more than a half hour to fall asleep at least three nights a week persists beyond a month, it's considered chronic. But, honestly, I wouldn't know if that applies to me anymore. Having taken the pills for three- to six-month stints, with short breaks, over the past five and a half years, I'm like a person who's been highlighting her hair so long she doesn't know what her natural color is.

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Ambien has gotten a lot of bad press recently for its adverse side effects: Kerry Kennedy crashed into a tractor-trailer on a New York highway, her explanation being that she'd mixed up her pill bottles and taken zolpidem instead of thyroid medication; then there was Tom Brokaw blaming an uncharacteristically loopy TV appearance on being under Ambien's influence; and, in January, the FDA's surprising recommendation that dosages be cut in half for female patients based on lab studies and driving tests that confirmed a risk of next-day drowsiness. (Women eliminate Ambien at a slower rate than men, the FDA said, and some still have enough in their system after eight hours to impair driving.)

But apart from an isolated incident in which I sent a PDF of a fan letter I'd received from a prisoner to an ex-boyfriend hoping to incite his jealousy (in case you're wondering, it didn't work) and some very vivid dreams, I can't complain about any side effects, not even the next-day hangover experienced by up to 8 percent of users, according to Ambien manufacturer Sanofi. And the truth is, for putting me out of my up-all-night misery, I can't sing the medication's praises enough: Almost every time I pop an Ambien, I fall into a warm, fuzzy, Serta commercial–quality slumber within minutes and sleep soundly for the entire night.

While I've always been a chronic ruminator—and had the occasional sleepless night throughout my adolescence—taking prescription sleeping pills never occurred to me until my senior year of college, when the uncertainty of postgraduation life sent me into an insomnia tailspin. After watching me repeatedly take Tylenol PM in vain (my body felt like it had been hit with a tranq dart, but my mind was still racing), one of my suite mates, who was something of a psychopharmaceutical adventuress, told me to look into Ambien. Her delivery—calm, nonchalant, no fine print—sold me. The way she made it seem, taking Ambien was about as risky as taking a daily vitamin. Why hadn't I thought of this before? I wondered, and made an appointment to see a doctor the next day.

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In some ways, this cavalier approach mirrored the American public's. When Ambien was approved by the FDA in 1992, it appeared to be something of a miracle drug. The then leading sleep aids, benzodiazepines such as Ativan and Halcion, were unquestionably effective at knocking out users by binding to the brain's GABA receptors, thereby inducing tranquility, but they had a major drawback: They could be habit-forming, highly so. Around that time, in fact, Time ran a story titled "The Dark Side of Halcion." Meanwhile, Ambien, one of a new class of medications called "z-drugs" (think zolpidem), represented progress: It still bound to GABA receptors, so put people to sleep in a matter of minutes, but in a way that seemed to lessen the risk of physical dependence. So enthusiastic were experts about Ambien's superiority over its forebearers that in a 1996 New York Times article, one doctor said that this new generation of sleep aids had no physical addiction risk whatsoever.

Note the term physical. This kind of dependence is often marked by "tolerance"—users need to take increasing amounts to get the same effect—and, when the drug is discontinued, by withdrawal symptoms, which can be anywhere from mild to life-threatening (the latter can be the case, for example, when hard-core alcoholics stop drinking cold turkey). Physical dependence is a component of addiction, but while the two words are often used interchangeably, they're not really the same thing. Cancer patients who take opioids for pain are physically dependent on them, but their lives are better with the medication than without it. By contrast, someone who's addicted to opioids, or anything else, compulsively consumes increasing amounts of the drug, virtually regardless of any harm she's doing to herself or others. And, in fact, Sanofi advises doctors to think twice before prescribing Ambien to people with a history of addiction.

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The rub with zolpidem, in fact, is that it can cause physical dependence if it's taken longer than recommended. And because of its potential to cause psychological dependence (a state in which a desired behavior or emotion feels beyond reach unless you take a particular substance), restricting yourself to short-term use—35 days on the outside, based on Sanofi's studies-—can be hard to do.

"Falling asleep is as mental as it is physical," says Carl Bazil, MD, PhD, a neurologist at Columbia University Medical Center who has criticized the overuse of sleeping meds. "This is where it can be hard to distinguish whether you really need a pill to fall asleep or you think you need a pill to fall asleep."

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I should know. I've tried to wean myself off Ambien, but as soon as I give in and take a capsule to help me with even one sleepless night, I'm hooked. The next night, I psych myself out, and the thought of falling asleep without what helped the night before seems impossible. Two nights become a week, a week becomes two weeks, and pretty soon I've blown right past the suggested time limit. "The inability to sleep is usually symptomatic of something else," Bazil says. "You need to deal with why you're not sleeping, or you'll need to take that pill."

But to play devil's advocate for a moment, is "needing" something to sleep really a problem if—and this is obviously a big "if"—you manage to stick to the recommended amount? Especially if the substance in question helps you function better? I've never taken more than 10 milligrams of Ambien at a given time—the maximum recommended dose for women until the FDA lowered it in January—and often use half or a quarter of that. My first answer to my own question is actually: Yes, it's a problem! It seems "bad," weak, just generally reprehensible to have to rely on a pill to feel a certain way or, more to the point, achieve the absence of feeling: sleep, glorious sleep. But then again, perhaps that's just knee-jerk puritanism or asceticism, or misplaced faith in human perfectibility.

Chronic sleep deprivation is, after all, associated with a laundry list of medical conditions, including increased propensity for high blood pressure, diabetes, obesity, depression, and a weakened immune system (though an association is not a cause, and it could be that these afflictions cause the insomnia, not the other way around). Inadequate sleep also has been shown to compromise brain power. The data from a 2000 Australian study, extrapolated for its effects on a 120-pound woman, indicated that just one sleepless night diminishes speed and accuracy on various cognitive tests as much as drinking three glasses of wine (or another alcoholic beverage).

There is a rather major piece of evidence, however, that contradicts taking a laissez-faire approach to Ambien and its fellow hypnotics. In a study published just over a year ago in the BMJ Open, the drugs were associated with triple the death rate for people who take as few as 18 doses a year compared with those who don't, and more than five times for those who take 132 doses or more (four and a half months' worth, if you take one a day)—which is quite a dramatic jump. To put it in perspective, a four-times-increased risk is what smokers have over nonsmokers of getting heart disease. (It's roughly 15 times for lung cancer.)

Other data has linked hypnotics to higher mortality too, but the BMJ study was large and well designed enough—based on the medical records of more than 10,000 enrollees in a Pennsylvania health plan—that the researchers were able to control for the physical health of the subjects. (A criticism of earlier work was that the elevated mortality among the sleeping-pill set was merely a byproduct of the fact that sick people take more sleeping pills.)

Among the theories offered by the investigators for the excess mortality (who didn't have access to causes of death): In some animal studies, there have been overdoses with hypnotics, especially when the meds are mixed with alcohol; the drugs might have carcinogenic properties—and, indeed, significantly higher rates of certain cancers, including lung, lymphomas, and colon, were detected in the Pennsylvania data set. Finally, there is the next-day hangover, and the possibility that fatal accidents account for part of the differential. (And, not incidentally, while research points to a slight increase in mortality rates related to too little sleep, the magnitude is not nearly as great as that of the pill-taker's.)

Because of such unsettling findings, and the small but real addiction potential, the neurologist Bazil says Ambien shouldn't be the first line of defense against insomnia. "I'd only prescribe it to a patient after considering several other options," he says.

Alas, Ambien is pretty much the only thing I've ever tried. But even though I don't think I'm on the verge of becoming a junkie, or anything close, I'm ready for a change. I was embarrassed when, on a recent trip to visit friends, my hosts found me frantically ripping through my suitcase after I'd discovered my Ambien bottle was empty. And I do believe what Bazil says, that insomnia is caused by "something." Maybe it's just too much coffee after 3 p.m., but it's time to find out what my something is.